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Content Article
NES: Safety culture discussion cards
PatientSafetyLearning Team posted an article in Good practice
Safety culture can be described as our: 1. Values (what is important) 2. Behaviours (the way we do things around here) 3. Beliefs (how things work). Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. NHS Education for Scotland (NES) has adapted these safety culture discussion cards (designed by EUROCONTROL) to help us to do this. Follow the link below to download the cards.- Posted
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Content ArticleNewly qualified nurses often fear making or identifying a clinical error so it is vital to know how best to prevent errors and manage them when they have occurred. This Nursing Times article looks at the most common clinical errors that are made, explains where to find the policies and procedures that should be followed, and highlights tips and tools that can be used to help rectify the issue or prevent it from happening in the first place.
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Content Article
e-PAIN: e-Learning on pain management
Claire Cox posted an article in Training & education
e-PAIN is the place to start for anyone working in the NHS who wishes to better understand and manage pain. e-PAIN is a multidisciplinary programme based on the International Association for the Study of Pain's recommended multidisciplinary curriculum for healthcare professionals learning about pain management. Registration to the programme is free to all NHS staff members, those with OpenAthens accounts and students. -
Content ArticleThis was the first Chartered Institute of Ergonomics and Human Factors (CIEHF) Pharmaceutical Sector group organised event, where the systems and human factors challenges of labelling and packaging were discussed by a wide-ranging audience across the healthcare and pharmaceutical sectors.
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Content ArticleFrontline staff and volunteers at the forefront of the national coronavirus response across England will be able to access a new Psychological First Aid (PFA) training course, the Minister for Mental Health Nadine Dorries announced, 15 June 2020. The free online course available through Future Learn enables responders to develop their skills and confidence in providing key psychological support to people affected by coronavirus, including on issues such as job worries, bereavement or isolation as they carry out their vital work as part of the ongoing coronavirus response. It will also help to develop understanding of how emergencies like the coronavirus pandemic can affect us all, how to recognise people who may be at increased risk of distress, and how to offer practical and emotional support. It follows a globally recommended model for supporting people during emergencies, tailored to the specific challenges of coronavirus (COVID-19)
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Content ArticleThe COVID-19 pandemic is challenging the Canadian emergency departments (EDs) in unparalleled ways. As part of the frontline response, EDs have had to adapt to the unique clinical difficulties associated with the constant threat of COVID-19, developing protocols and pathways in the setting of limited and evolving information. In addition to the disruption of routine clinical care practices, an underlying perception of danger has resulted in a challenging clinical environment in which to make time-sensitive, high-stakes decisions. This has created an urgent need for targeted and adaptive training for all members of the emergency medicine healthcare team. The following commentary, published here by the Cambridge University Press, reflects the perspective of four emergency medicine simulation educators during the Canadian response to COVID-19.
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Content ArticleDr Susan Whalley-Lloyd, Senior Lecturer in Human Factors/Ergonomics at Staffordshire University, explains in this short video presentation why a human factors course is important for patient safety and what the course at Staffordshire University covers.
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Content ArticleIn this commentary published in the Journal of Patient Safety and Risk Management, Gurses et al. describe how human factors and ergonomics (HFE) can contribute to the COVID-19 pandemic response. Specifically, the authors provide an example of how HFE methodologies informed workflow redesigns implemented as part of COVID-19 pandemic preparations in an academic paediatric ambulatory clinic. They identify key mechanisms and areas where HFE can contribute to and improve the effectiveness of a pandemic response: Just-in-time (JIT) training development, adapting workflows and processes, restructuring teams and tasks, developing effective mechanisms and tools for communication, engaging patient and families to follow the recommended practices (e.g., social distancing, revised hospital visitation policies), identifying and mitigating barriers to implementation of plans, and learning from failures and successes to improve both the current and future pandemic responses.
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Content ArticleROSPA's one-day accident investigation training will give you a broad understanding of the accident investigation process, looking at the benefits of accident prevention and putting the emphasis on practical training exercises and real-life case studies. Training is suitable for line managers, supervisors, safety representatives – and anyone with the responsibility for investigating accidents. It will enable organisations to meet their moral and legal obligations to investigate accidents and incidents and learn from safety failure.
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Content ArticleNEBOSH and Great Britain’s Health and Safety Regulator, the Health and Safety Executive (HSE), have jointly developed a new one day qualification that shows how non-complex incidents can be investigated effectively. By learning lessons and making improvements, organisations can avoid similar incidents occurring in the future.
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Content ArticleHelen is a Consultant Anaesthetist at the Oxford University Hospitals NHS Foundation Trust (OUHFT) and a Senior Clinical Research Fellow in the Nuffield Department of Clinical Neurosciences, University of Oxford. Here, Helen highlights the importance of support and training and gives an example of how the OxSTaR team are transforming staff teamworking skills and improving patient safety.
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Content ArticleA research paper published by researchers from the Johannes Kepler Universität and the University of Applied Sciences, both in Austria, examined the process of developing what is termed as a ‘constructive error culture’ in organisations. This Research Brief from Oxford Review summarises the findings.
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Content ArticleSafety and improvement efforts in healthcare education and practice are often limited by inadequate attention to human factors/ergonomics (HFE) principles and methods. Integration of HFE theory and approaches within undergraduate curricula, postgraduate training and healthcare improvement programmes will enhance both the performance of care systems (productivity, safety, efficiency, quality) and the well-being (experiences, joy, satisfaction, health and safety) of all the people (patients, staff, visitors) interacting with these systems. Patient safety and quality improvement education/training are embedded to some extent in most curricula, providing a potential conduit to integrate HFE concepts. To support this, Bowie et al. in this article published in Medical Teacher offer professional guidance as “tips” for educators on fundamental HFE systems and design approaches. The goal is to further enhance the effectiveness of safety and improvement work in frontline healthcare practice.
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Content ArticleIn this book, you’ll learn the definitions behind the 4-point process of patient activation. It will also share how leading health care organisations and other clients have successfully used the model in a wide range of different initiatives. Along the way, you will gain specific techniques for applying patient activation in your own efforts. In this book, patient activation will refer to a fully integrated system to move from awareness to action.
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Content Article
COVID-19: guidance for health professionals (Coronavirus)
Claire Cox posted an article in Guidance
Information on COVID-19, including guidance on the assessment and management of suspected UK cases. -
Content Article
Ten Thousand Feet: workshops and consultancy
Claire Cox posted an article in Suggest a useful website
Ten Thousand Feet UK is a Consultancy led by Rob Tomlinson in collaboration with the Association for Perioperative Practice. Rob is a clinical nurse in the NHS and is leading the way to improving patient safety through clinician-led culture change in the UK. Rob has already delivered workshops on a national scale with success for teams who have embraced the new procedure. 'Never Events' within the NHS are still on the rise with distraction and a loss of situational awareness still being cited as one of the main causes. Ten Thousand Feet aim to embed new patient safety culture into operating theatre teams nationwide, so at any time, anyone working in the theatre who needs to focus their attention at the task in hand can can use the language tool “Ten Thousand Feet” to improve team efficiency and most importantly patient safety. At the end of the workshop theatre staff will be educated and empowered to use this concept in a safe and effective manner. -
Content Article
AWARE – Well-being resources
Patient Safety Learning posted an article in Good practice
A suite of resources designed to promote well-being among US residents, fellows, faculty members, and others has been created by the Accreditation Council for Graduate Medical Education. This initial set of AWARE resources focuses on individual strategies for cognitive skill building, and includes a video workshop, podcasts, and the ACGME AWARE app. -
Content Article
Coroners, post-mortems and inquests
Claire Cox posted an article in Coroner reports
Coroners are independent judicial officers who investigate deaths reported to them. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest. -
Content ArticlePresentation from WHO's 'A Decade of Patient Safety 2020-2030: Formulating Global Patient Safety Action Plan' patient safety meeting in Geneva.
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Content ArticlePatient Safety Learning has submitted the attached response to the consultation for the national patient safety syllabus. The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’. A key action associated with this aim is the creation of a system-wide patient safety syllabus which is capable of ‘producing the best informed and safety-focused workforce in the world’. The Academy of Medical Royal Colleges (AOMRC) has been commissioned by Health Education England (HEE) to develop a new National patient safety syllabus. The Academy has now published its first version of this for review and feedback. At Patient Safety Learning, we’ve been working with the AOMRC and HEE in the initial stage of development to share our thoughts on the initial proposals in this syllabus. Now that this has been formally published for consultation, we want to share our submission as part of the consultation process which closed on Friday 28 February 2020. We welcome the development of a National patient safety syllabus and believe that it’s very important that this acts as a key driver for achieving a step change in patient safety across the NHS. In our response to the consultation we identify several areas where there are significant gaps in the initial draft that need to be addressed and comment on the development process of the syllabus, inviting a more inclusive and transparent process that enables a wide range of stakeholders to engage and contribute.
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Content ArticleSteve Turner's blog look at a workshop session delivered jointly by a facilitator and a user of mental health services. The aims of the session were to discuss adherence to medicines and treatments, relate this to practice through group work and discuss this with a user of mental health services
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Content ArticleIn his blog, Danny Tucker, Associate Professor in Obstetrics & Gynaecology and Director of Clinical Training, describes how clinicians experience two types of learning: firstly, incremental learning – they study new facts, medical knowledge and technical skills. Through incremental learning, individuals align habits with established norms, conform to ideals laid out by experts and reinforce existing power structures. Incremental learning involves the process of deliberate practice. Mezirow introduced the concept of transformative learning. This is a deeper, developmental shift, where situations and dilemmas challenge underlying assumptions and beliefs about the world. Clinicians grow through reflective engagement with their experiences, the people they meet - particularly patients - and by testing new mental models of how the world works. Transformative learning changes perspectives and relationships, laying the foundation for personal growth and innovation. It requires curiosity, attention, and courage. Danny offers practical steps that can be taken to encourage and inspire transformative learning for doctors in training.
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Content ArticleThis inquiry looked at the current and future scale of the shortfall of nursing staff and whether the Government and responsible bodies have effective plans to recruit, train and retain this vital workforce. It assessed the impact of new routes into nursing (including student funding reforms, the Apprenticeship Levy, Nurse First and nursing associates). In particular, the inquiry examined the effect of changes to funding arrangements for nurse training, including the withdrawal of bursaries, and consider alternative funding models and incentives.
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Content ArticlePresentation from Joanna Lloyd, Bevan Brittan, on incident investigations.
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Content ArticleResilient Health Care (RHC) is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is by Sujan et al., published in Safety Science, was to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout.
